Nokea
The nurse chooses to use touch in the nurse-patient relationship because touch:
- A. can convey caring and support when words are difficult.
- B. should be avoided because of problems of cultural misinterpretation.
- C. is appropriate only in special circumstances, such as with young children.
- D. is a nursing intervention of choice in almost all situations.
Correct Answer: A
Rationale: The correct answer is A because touch can convey caring and support when words are difficult, enhancing the nurse-patient relationship. This is supported by research showing the positive impact of touch in providing comfort and building trust. Choice B is incorrect as cultural differences can be addressed through communication and understanding. Choice C is incorrect because touch can be appropriate in various situations beyond just young children. Choice D is incorrect as touch should be used judiciously based on individual preferences and boundaries.
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A patient tells the nurse that she dislikes the food that is served in the hospital. The nurse responds, "Our cooks work very hard; the food that is served is very good." The nurse's response is an example of the communication block of:
- A. judgmental response.
- B. giving advice.
- C. defensive response.
- D. using clichés.
Correct Answer: C
Rationale: The correct answer is C: defensive response. The nurse's response deflects the patient's complaint about the food quality by defending the cooks' efforts instead of addressing the patient's concerns. This can create a barrier to effective communication by dismissing the patient's feelings and not acknowledging their perspective.
A: Judgmental response involves criticizing or making assumptions about the patient, which is not evident in the nurse's reply.
B: Giving advice would involve offering suggestions on how to improve the situation, which the nurse did not do.
D: Using clichés would involve using overused phrases that may not directly relate to the patient's concern, which is not the case in this scenario.
In summary, the nurse's defensive response fails to address the patient's complaint and can hinder effective communication by dismissing the patient's feelings.
The characteristic that is representative of the nurse-patient relationship is that this relationship:
- A. focuses on the nurse's ability to build rapport.
- B. continues after discharge.
- C. does not include humor.
- D. focuses on the assessed patient health problems.
Correct Answer: D
Rationale: The correct answer is D because the nurse-patient relationship primarily focuses on addressing the assessed health problems of the patient. This relationship is centered around providing care, support, and assistance related to the patient's health needs. Building rapport (A) is important, but not the primary focus. The relationship does not necessarily continue after discharge (B) as it depends on the circumstances. Humor (C) can be included in the relationship but is not a defining characteristic. Thus, D is the correct choice as it aligns with the fundamental purpose of the nurse-patient relationship.
The nurse is caring for a patient who states, "I tossed and turned last night." The nurse responds to the patient, "You feel like you were awake all night?" This is an example of:
- A. open-ended question.
- B. restatement.
- C. reflection.
- D. offering self. Restatement is a
Correct Answer: B
Rationale: The correct answer is B: restatement. Restatement involves repeating the patient's words to confirm understanding. In this scenario, the nurse echoed the patient's statement to show empathy and acknowledge the patient's feelings. This technique helps build rapport and fosters therapeutic communication.
Explanation of why other choices are incorrect:
A: Open-ended question: This involves encouraging the patient to elaborate on their feelings or experiences, not just repeating what the patient said.
C: Reflection: This involves restating the patient's feelings to show understanding, not simply repeating their words.
D: Offering self: This involves offering oneself to the patient for support, which was not demonstrated in the scenario.
The nursing staff are making suggestions about how to help Ms. C (bowel resection) overcome her reluctance to perform colostomy care. Which suggestion will the team leader try first?
- A. Verbally reexplain the procedure and give her written material.
- B. Have a family member come in and do it for her.
- C. Continue to do it for her until she is ready.
- D. Ask her to hold the clamp while the bag is being emptied.
Correct Answer: A
Rationale: The correct answer is A because it involves providing Ms. C with information and resources to help her understand and feel more comfortable with the colostomy care procedure. Verbally reexplaining the procedure and providing written material will empower her with knowledge and autonomy. Choice B undermines her independence and may not address her reluctance. Choice C promotes dependency rather than encouraging her to take ownership of her care. Choice D involves a hands-on approach that may not address her underlying concerns or fears about the procedure. Overall, choice A is the most appropriate initial step to support Ms. C in overcoming her reluctance.
The nurse cares for a client with abdominal pain who is scheduled for exploratory surgery. Which statement(s), if made by the nurse, indicates that the client's rights in the helping relationship have been violated? (Select all that apply)
- A. "I do not have time right now to help you call your family."
- B. "I am available to answer questions that you may have about your surgery."
- C. "You seem frightened. I will stay with you until your family arrives."
- D. "Your neighbors called, and I told them that you will have surgery."
Correct Answer: A
Rationale: The correct answer is A because by stating, "I do not have time right now to help you call your family," the nurse is not respecting the client's autonomy and right to involve their family in decision-making. This violates the client's right to information and support.
Choices B and C are incorrect because they demonstrate the nurse's willingness to provide information, support, and emotional care, which align with the client's rights in the helping relationship.
Choice D is incorrect as it shows the nurse informing the client about the neighbors' call, which may not necessarily violate the client's rights unless the client explicitly expressed a desire for privacy.